PGAP assessment
Part 2. Data Collection Sheet / Intake Form ( 20 points)
Client Initials: M/F Age: Student: Date:
NOTE: Insert data into the table using short responses and/or bullets; Use medication terminology as if documenting in a medical record. Word process right in the table cells and let the paper expand as needed. Do not remove the table format, alter questions, or try to submit the assignment into an alternative format.
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Introduction Questions to ask your client: |
(use client’s words) |
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1. Would you rate your current state of health as excellent, good, fair, or poor?
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2. Why did you select this rating?
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3. What does it mean to be health as you age?
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1. Medications
-prescription & over the counter
NOTE : If 5 or more meds (Rx or OTC)
Polypharmacy: consider side effects & drug-drug interactions, effectiveness, Risk/benefit, etc.
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Medication, Dose, Frequency |
Diagnosis/ Indication |
Effective for condition? (Y-N) |
Drug Duplication? (Y-N) |
Side Effects and/or Lab Monitoring |
Poly-pharmacy (Y-N) |
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2. |
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3. |
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4. |
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5. |
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6. |
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7. |
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8. |
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Client Findings |
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2. Identify medical problems based on Review of Body Systems and their functional impact.
-Refer to Mauk Ch. 6- Functional Assmt or Independent Activities of Daily Living (IADLs)
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Review of Systems/Current Medical Problems |
Any Impact on Function? (describe) |
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1. Cardiovascular |
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2. Respiratory |
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3. Gastrointestinal |
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4. Genitourinary |
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5. Neuro/Mental Health |
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6. Musculoskeletal |
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7. Immune |
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8. Hematic/Blood |
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9. Integumentary
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3. Previous surgeries and/or health problems
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4. Education level, Occupation & age at retirement-
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5. Recent and impending life changes (deaths, moves, stressors, hospitalizations, COVID?)
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6. Racial/Cultural/Gender preferences/Language Preference
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7. What activities engaged in to maintain or improve health? How does this affect their personal and social functionality?
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8. Current and future living environment and its appropriateness to ADL function and long-term prognosis? How does it contribute to their health? Is it appropriate? Any safety concerns? (stairs, handrails, shower chair, throw rugs, clutter, laundry, etc.)
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9. Family situation and availability. Provide details. (where they live, how often they visit, what they help with, etc.)
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10. Current caregiver network including its deficiencies and potential for improvement.
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11. Objective measure of cognitive status, forgetfulness, affect & mood, etc. Explain.
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12. Objective assessment of mobility, balance, previous falls, ability to drive a car. level of physical activity. Explain.
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13. Rehabilitative status, prognosis, how long they can be expected to stay in current living situation? Assistance or home modifications needed?
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14. Current emotional/mental health and substance use/abuse? Explain.
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15. Religious affiliation & significance. Explain.
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16. Nutritional status, Ht/Wt BMI Calculator, who grocery shops, what do they have in the fridge/cupboards, who cooks, describe typical meals? Community resources? Explain.
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17. Preventive health, immunizations, screenings, and health promotion activities.( include dates )
CLICK on the Resource content tabs & apply to your client.
**if no dates, include a plan to address deficit on the Health Promotion problem list & significant intervention in the section below. |
Immunizations Click below: |
Screenings Click below: |
Health Promotion Click below: |
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Vaccines & DATES : Pneumovax (15-20-23) Tetanus Shingles RSV Flu COVID Etc. |
Screenings & DATES: Atrial Fibrillation-EKG Osteoporosis-Dexascan Diabetes- Breast Cancer- Mammogram Prostate Cancer-PSA Colon Cancer- (consider age) Skin Cancer Depression/suicide risk Hearing/Vision Other |
Other areas to ask about: Alcohol Drug use Smoking Dentist Eye Exam
Advanced Directive-Location (Ask - What Matters Most if health declines )
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18. Services & resources. (home care, Soc Security, pensions, health insurance, community programs). Explain.
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19. Technology available in the home. Describe: (land-line telephone, computer skills, electronic tablet, internet, smart phone, electronic gadgets, electronic banking, Access to Online Medical Record, etc.)
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20. Any legacy plan to address the future needs of your family, such as birthdays/weddings/educational needs, or pet care arrangements after your passing.
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Concluding Questions to ask your client: |
(use client’s words) |
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1. What suggestions do you have for others about health in aging? |
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3. What suggestions do you have for nurses/health care providers/NH administrators about health in the elderly? |
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NURS 420: P-GAP p 3 of 12
NURS.420.Su2025 njs©
Updated 8.2026 JPederson
Part 3: Functional Assessment (5 points)
Select One: SPICES, Lawton, or Katz (Select one-- cannot be used in Section 4)
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Try This Tool Utilized |
Description of Tool include brief description, sample questions, etc. |
Pt. Score & Interpretation Include scoring range, interpretation of score |
Frequency of Follow-up and/ or Repeat Screening |
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1. |
*
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Part 4: 5 “TRY THIS” Assessments (25 points)
Your goal is to use a tool that will lead to a significant intervention
- use critical thinking and clinical reasoning skills to determine which tool to utilize
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Try This Tool Utilized |
Description of Tool include brief description, sample questions, etc. |
Pt. Score/ Interpretation scoring range, and interpretation of range of scores |
Follow up needed? (Yes/No) Frequency of Follow-up and/ or Repeat Screening |
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1. Mental Health - choose one: -Geriat. Depression Scale -Mini-Cog -MoCa
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2. Heinrich II Fall Risk
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3. Nutrition
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4. Your Choice (TRY THIS tool only)
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5. Your choice (TRY THIS tool only)
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Part 5: Identify Opportunities for Intervention Supported by Data Intake/TRY THIS ( 10 points)
Students must demonstrate critical thinking to recognize pertinent data from parts 2-4 ( Red flags) to identify care gaps that will inform your interventions and goals in part 6.
All data must come directly from your Data Intake Form and Try This® assessments. No new data should be added in this section.
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Focused Area for Intervention |
Evidence from data intake/TRY THIS screening assessments
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1. Matters Most: Advanced Directives, Vaccination gap, or Leaving a legacy
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2. Mental Health Consider socialization, technology or impact of COVID isolation
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3. Medication Consider polypharmacy (Rx or OTC) & side effects |
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4. Mobility- Consider level of physical activity, fall risk, or driving concerns
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5. Meals or Nutritional Status Consider BMI, diet restrictions for disease & protein consumption
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Part 6: SMART Goals & Significant Interventions (20 points)
1. Utilize your care gaps identified in part 5 to find evidence-based practice (EBP) interventions and create SMART goals
2. Your “Significant Interventions” must come from EBP journal articles published in the past 5-10 years which support the intervention as well as your specific client needs. These articles will be summarized in part 7.
3. Create patient-focused SMART goals, written in one sentence, highlighting the intervention. SMART goals must be S-specific, M-measurable, A-achievable, R-realistic, T-timely.
Sample SMART goals: Client will get XXX vaccination at the clinic by June 1, 2023.
J.R. will access online medical record and print out vaccination record by June 1, 2023.
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Opportunities for Improvemement |
Significant Intervention Highlighted in the EBP article |
SMART goal |
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1. Matters Most Focus on vaccination gap or Advanced Directive opportunity
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2. Mental Health Focus on socialization, gero-technology, or engagement with their healthcare with EMR access
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3. Medication Focus on polypharmacy or side effects |
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4. Mobility Focus on level of physical activity, fall risk, or driving concerns |
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5. Meals/Nutrition Focus on BMI, diet restrictions for disease & protein consumption
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Part 7: Annotated Bibliography of Evidence-Based Interventions (10 points)
In this section, summarize the EBP articles utilized to create your part 6 interventions and SMART goals.
In one paragraph (no more than 150 words) identify the study design, summarize the article findings, and apply those findings to your client and your chosen intervention.
The articles must come from peer-reviewed journals. The paragraph may be single-spaced.
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ARTICLE #1: Matters Most Intervention APA Citation:
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Summary (150 words max)
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ARTICLE #2: Mental Health Intervention APA Citation:
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Summary (150 words max)
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ARTICLE #3: Medication Intervention APA Citation:
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Summary (150 words max)
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ARTICLE #4: Mobility Intervention APA Citation:
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Summary (150 words max)
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ARTICLE #5: Meals/Nutrition Intervention APA Citation:
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Summary (150 words max)
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Part 8: Self-Evaluation ( 5 points)
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Write a 200-300 word summary, single-spaced, in APA format describing a theory of aging and how it applies to your client’s agingprocess, health status, and functional changes. Reflect on how this assignment has helped with experience and confidence in taking a leadership role in client assessment and applying evidence-based practice in a home setting.
Please save and submit your document with the following format: LAST NAME_ assignment title_ date. Example: Pederson_PGAP_2026
P-GAP Grading Rubric *** For Instructor Use When Grading
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Part |
Assignment Element |
Possible Points |
Points Earned |
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1 |
Signed Consent (with client phone number) |
5 |
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2 |
Data Collection Criteria: thorough, organized, succinct (avoid full sentences)
COMMENTS: |
20 |
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3 |
Functional Assessment Choose from: SPICES, Lawton, or Katz Criteria: description and interpretation
COMMENTS: |
5 |
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4 |
5 TRY THIS screening assessments Includes: mental health, fall risk, pain, plus 2 more priority needs Criteria: include description, interpretation, and address follow-up -5 points per TRY THIS tool
COMMENTS: |
25 |
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5 |
Identify Opportunities for Intervention Supported by Data Intake/TRY THIS - 5 areas x 2 points for each area
COMMENTS: |
10 |
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6 |
SMART Goals & Significant Interventions Intervention Criteria: significant intervention aligned with article summarized in part 7 SMART goal Criteria: one sentence with a specific, measurable, attainable, relevant, and time-bound goal -2 points for each EBP intervention x 5 interventions -2 points for each SMART goal x 5 goals
COMMENTS: |
20 |
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7 |
Annotated Bibliography Criteria: aligned with intervention, includes brief article summary, and relevance to client -2 points per article
COMMENTS: |
10 |
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8 |
Self –Evaluation Includes: aging theory, leadership role, client assessment, evidence-based practice Criteria: 200-300 words, APA format
COMMENTS: |
5 |
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Total
Note: up to 5 points may be deducted for grammar, spelling, neatness.
COMMENTS: |
100 possible |
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